Lumbar hernia

Lumbar hernia

Most primary lumbar hernias occur through the inferior lumbar triangle of Petit, bounded below by the crest of the ilium, laterally by the external oblique muscle and medially by latissimus dorsi ( Figure 64.23 ). Less commonly , the sac comes through the superior lumbar triangle, which is bounded by the twelfth rib above, medially by sacrospinalis and laterally by the posterior border of the internal oblique muscle ( Figure 64.24 ). Primary lumbar hernias are rare, but may be Jean Louis Petit , 1674–1750, Director of the Academie de Chirurgie, Paris, France. - mimicked by incisional hernias arising through flank incision operations. Differential diagnosis A lumbar hernia must be distinguished from: /uni25CF a lipoma; /uni25CF an incisional hernia, such as from a renal operation; /uni25CF a cold (tuberculous) abscess pointing to this position; /uni25CF a pseudohernia due to local muscular paralysis. Lumbar pseudohernia can result from any interference with the nerve supply of the a ff ected muscles, the most common cause being injury to the subcostal nerve during a kidney operation. Treatment The natural history is for these hernias to increase in size and surgery is recommended. Lumbar hernias can be approached by open or laparoscopic surgery . The defects can be di ffi cult to close with sutures alone and mesh is recommended. The TAPP laparoscopic approach is gaining popularity for small hernias. With the patient in a semilateral position ports are inserted well away from the defect. The peritoneum is incised above the hernia and dissected back to expose the mus - cle defect. The content, often extraperitoneal fat, is reduced and a mesh fixed with ample overlap. The peritoneum can then be resutured or tacked back to cover the mesh. Lumbar incisional hernias can be approached in the same way; howev er, large ones can be very di ffi cult, especially if there is a component of neuropathic muscle atrophy causing a di ff use b ulge (pseudohernia).

Figure 64.23 Inferior lumbar hernia, which contained caecum, appendix and small bowel. Note the /f_i larial skin rash on the buttocks (courtesy of VJ Hart /f_i eld, formerly of south-east Nigeria). Figure 64.24 (a) Left superior lumbar hernia, containing only extraper

itoneal fat. (b) Computed tomography scan of a similar but right-sided superior lumbar hernia. Emerging just below the twelfth rib, it is level with the right kidney and the right lobe of the liver.